Nursing Elites

1. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

• A. corner of the mouth to tragus of the ear
• B. corner of the eye to top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: D

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

2. Which of these would be the most appropriate way to document a client's refusal of medication?

• A. "Heparin refused during shift. Risks reviewed."?
• B. "The client refused the heparin injection when I tried to administer it. She yelled at me, saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift."?
• C. "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
• D. "Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct, and the ct verbalized understanding."?

Correct answer: C

Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.

3. Which of the following activities is not part of client advocacy?

• A. involving the client in treatment and decision-making
• B. standing up for what is right for the client
• C. sharing your personal opinions to help provide additional information
• D. encouraging the client to advocate for themselves

Correct answer: C

Rationale: The correct answer is 'sharing your personal opinions to help provide additional information.' Client advocacy involves supporting the client's autonomy and choices. It is essential for the nurse to involve the client in treatment and decision-making (Choice A) to ensure their preferences are considered. Standing up for what is right for the client (Choice B) is also a crucial aspect of advocacy, ensuring their rights and well-being are protected. Encouraging the client to advocate for themselves (Choice D) empowers the client to express their needs. However, sharing personal opinions (Choice C) may influence the client's decision-making process and is not a recommended practice in client advocacy, as it can compromise the client's autonomy.

4. The nurse should teach parents of small children that the most common type of first-degree burn is:

• A. scalding from hot bath water or spills.
• B. contact with hot surfaces such as stoves and fireplaces.
• C. contact with flammable liquids or gases resulting in flash burns.
• D. sunburn from lack of protection and overexposure.

Correct answer: D

Rationale: The correct answer is 'sunburn from lack of protection and overexposure.' First-degree burns primarily affect the outer layer of the skin and are commonly caused by overexposure to the sun without adequate protection, making it a significant concern for parents of small children. Choices A, B, and C describe other types of burns (scalding, contact with hot surfaces, and contact with flammable substances) that can cause more severe burns beyond the first-degree level. It is crucial for parents to be educated about sun safety measures to prevent sunburns in children.

5. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

• A. exercising vigorously for 20 minutes each night starting at 9:30 p.m.
• B. taking a cool shower and drinking a hot cup of tea
• C. watching TV nightly until midnight
• D. getting a back rub and drinking a glass of warm milk

Correct answer: D

Rationale: Getting a back rub and drinking a glass of warm milk are appropriate measures to promote sleep as they can help relax the body and induce sleepiness. Exercising vigorously, as suggested in choice A, can be counterproductive as it stimulates the body rather than relaxing it, making it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, may also increase alertness due to the temperature changes and the caffeine in tea, which can interfere with falling asleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, making it harder to fall asleep. Therefore, choice D is the best option to promote sleep in this scenario.

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